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Appendix VI <br />Underground Storage Tank <br />Monitoring System Certification Form <br />TYPE OF ACTION Ll Installation D Repair R 12 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />Certification Date <br />10181655 <br />02/13/2023 <br />Facility Name <br />Chevron 372736 <br />Facility Address <br />City <br />ZIP ,Code. <br />9484 West Lane <br />Stockton <br />95210 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification Phone <br />Tanknology, Inc. 800-964-1250 <br />Mailing Address <br />11000 N Mopac Expy #500 Austin, Tx 78759 <br />Service Technician Performing Test <br />Jesus Saldivar <br />Contractor/Tank Tester License Dumber <br />Class A General Engineering 743160 <br />ICG Number ICC Expiration Date <br />8361393 06/11/2023 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Veeder Root:VR Level 4 (645334) <br />04/21/2023 <br />VM I:TLDT-5000 Tester (3802) <br />11/07/2023 <br />OPW:EVR Phase 1 (104302) <br />01/04/2025 <br />PELRP1200 (Nove) 06/05/2079 <br />4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br />I hereby certify that rhe inoairoring system is operational rn accordance with Cafifornia Code <br />ofRegufations. title 23, division 3, chapter 75, section 2635; that required supportit) g <br />documentation is attached; and ail information contained herein is accurate. <br />Service Technician Signature <br />Date <br />Total # of Pages <br />All W.41— <br />02/13/2023 <br />6 <br />CERS = California Environmental Reporting System, GPH = Gallons Per Hour, ID = Identification, <br />IGC = International Code Council, LLD = Line Leak Detector, NA = Not Applicable, SW = Single - <br />Walled, UDC = Under -Dispenser Containment; UST = Underground Storage Tank, <br />VPH = Vacuum/Pressure/Hydrostatic <br />Page 1 of 6 <br />